rheumatoid arthritis & treatment Flashcards
- chronic autoimmune inflammatory disease where the synovial tissue is inflamed and locally destructive with increased mortality and morbidity
- can also affect skin, eyes, heart, lungs, nerves
- often remission during pregnancy
rheumatoid arthritis
list 3 pathogenic factors for RA
- hormones– more common in women
- cigaretes
- infections- oral bacteria, viruses, microbiome
common digital manifestations of RA (4)
- Swan neck deformity of the hand
- Boutonnier’s deformities & nodules
- MCP erosions
- Ulnar deviation/subluxation
6 common extra-articular manifestations of RA
- scleritis
- corneal perforation
- vasculitis
- ILD- honey combing;
- pericarditis/pleuritis
- synovitis
- autoantibody against the Fc portion of IgG; high titer associated w/ severe dz, erosions, nodules, extraarticular manifestations
- not specific for RA– Sjogren syndrome, infections, healthy individuals
- higher titers equals more severe disease
rheumatoid factor
possibly pathogenic antibody; sometimes in TB, ILD, smokers and relatives of patients with RA
* associated w/ earlier joint damage
anti CCP
which hand joints are affected with RA?
MCP, intercarpals
IP joints are spared!!
often suddent onset at any age; commonly has systemic symptoms; joint exam shows swelling and deformities
+++ joint effusions and synovial thickening
erosions on xray
RA
3 joints that RA rarely affects
DIP/IP joints
T/L spine
hip
indirect measure of inflammation affected by RBCs, fibrinogen and immunoglobulins; correlates with joint damage/erosions
ESR
lab test NOT dependent on RBC #, made in liver & also correlates with joint damage/erosions
CRP
what test may correlate with disease activity
CCP antibodies (NOT RF)
4 main causes of mortality with RA
- coronary artery disease
- non-hodgkin’s lymphoma
- ILD
- medication ADR– bleeding, infections
SE includes gastritis, ulcers, reduced GFR, edema, kidney failure, MI, HTN, HA, etc
interacts with warfarin
NSAIDs
what class? 2 meds within the class
used as temp. tx until other meds take effect; use lowest dose for shortest time; IM injections stop a flare;immunosuppressive
steroids– prednisone 10-30mg & triamcinolong acetonide 40-120 mg IM
what medication? what must be monitored? what must be done before start?
- blocks dihydrofolate reductase, purine & pyrimidine; increases extracellular adenosine
- ADR: transaminase elevation, fatigue, nausea, diarrhea, cytopenias, HA, acute interstitial pneumonia
- 6 months to full effect
- decreases B,T & monocyte cell activity
- Methotrexate
- monitor CBC, transaminase & creatinine Q 3 months
- must do TB screening & pregnant test before starting
first line tx for mod/severe RA if not pregnant? if pregnant?
- Methotrexate
- Sulfasalazine or Hydroxychloroquine if pregnant
what med? what must you do prior to staring this med?
- immunomodulator that blocks Toll Like Receptors (TLR) w/ 6 months to action
- ADR– retinopathy related to cumulative dose, GI issues, myopathyrash, HA, depression
hydroxychloroquine
- must do visual exam and yearly after 5th yr
- immunomodulating drug that inhibits IL-2 induced T cell proliferation, changes B lymphocyte function & reduces cytokines
- ADR: nausea, SJS, bone marrow issues, HA
sulfasalazine
not for sulfa allergies
what 3 meds are used in triple therapy treatment?
sulfasalazine
hydroxychloroquine
methotrexate
what class? what should be screened before starting>
SE: infections, chills & HA (infusions), rash (injections)
CI: COPD, CHF
anti-TNF inhibitors
- infliximab (infusion), adalimumab, etanercept
- screen for TB, hep B & C
what class?
- blocks intracellular pathways following membrane activation
- SE: infections, abnormal LFTs, neutropenia, elevated lipids or creatitne, DVT, MI?, cancer
JAK inhibitors– tofacitinib, baricitinib, upadacitinib
- blocks costimulatory signal for T cell activation
- used alone or with methotrexate or other DMARDs
- infused monthly; injected 125mg weekly
- SE: rare infusion rxns, infections
T-cell activation inhibitor (abatacept)
- used in active RA as 2nd or 3rd line tx
- ADR: elevated liver tests, hyperlipidemia, increased infection risk
IL-6 inhibition– tocilizumab & sarilumab
how does treatment affect disease progress?
can achieve full remission & improve survival
4 main components of the points based diagnosis for RA? how many points needed?
- inflammatory arthritis in 3+ joints
- RF or anti-CCP
- elevated CRP or ESR
- duration over 6 weeks
need at least 6
